Associations between intracranial haemorrhage and prescribed prophylaxis in a large cohort of haemophilia patients in the United States.

Intracranial haemorrhage (ICH) is the most serious type of bleeding for patients with haemophilia. Prior published reports regarding ICH predate the widespread provision of prophylaxis. Our study objectives were to determine risk factors for ICH and whether prophylaxis reduces ICH occurrence. We performed a nested case-control study of persons with haemophilia, ≥2 years of age enrolled in the Centers for Disease Control and Prevention Universal Data Collection project. Of 10 262 patients 199 (1·9%) experienced an ICH for an incidence rate of 390/105 patient years. Head trauma was reported in 44% (88/199). ICH mortality was 19·6% (39/199). Significant risk factors for ICH included a high titre inhibitor [odds ratio (OR) = 4·01, 95% confidence interval (2·40-6·71)], prior ICH [OR = 3·62 (2·66-4·92)] and severe haemophilia [OR = 3·25 (2·01-5·25)]. Prophylaxis was associated with a significant risk reduction for ICH occurrence in patients with severe haemophilia who were negative for human immunodeficiency virus or an inhibitor, with an OR of 0·52 (0·34-0·81) and 0·50 (0·32-0·77) respectively. The most significant risk factors for ICH included the presence of an inhibitor, prior ICH, severity of haemophilia and reported head trauma. This is the first study to demonstrate that prescribed prophylaxis conferred a protective effect against ICH in patients with uncomplicated severe disease.

Hypoalbuminemia predicts acute stroke mortality: Paul Coverdell Georgia Stroke Registry.

BACKGROUND: Mortality remains unacceptably high among patients hospitalized for acute stroke. Additional knowledge about factors that contribute to mortality after stroke is important for instituting therapies to lower mortality. We sought to determine the factors that predict mortality in patients hospitalized for acute stroke. METHODS: In all, 1477 consecutively admitted patients with acute stroke in 34 hospitals in the state of Georgia participating in the Paul Coverdell Georgia Stroke Registry during a 3-month period (December 1, 2001-February 28, 2002) were identified by retrospective chart review using primary or secondary International Classification of Diseases, Ninth Revision codes. Of patients, 31% were black, 65% were white, and 58% were women. We determined inhospital mortality after admission for acute stroke in this representative group of patients. RESULTS: There were 154 (10%) inhospital deaths among the 1477 patients admitted with acute stroke. Univariate analysis showed that mortality was associated with older age (P = .0008), stroke type (P = .0051), Glasgow Coma Scale score less than 9 (P < .0001), decreased serum albumin (P = .0001), elevated creatinine (P = .0067), and elevated blood glucose (P = .0063). In the multivariate analysis, independent risk factors for mortality after acute stroke included older age (P = .004), stroke type (P = .0007), Glasgow Coma Scale score less than 9 (P < .0001), and decreased serum albumin (P = .0003). There was no relationship between race and inhospital mortality (P = .9041). In addition, there was no association between independent predictors and race. CONCLUSION: In addition to previously recognized predictors of inhospital mortality, we found hypoalbuminemia to be an independent predictor of mortality in a biracial cohort of patients with acute stroke.

Neighborhood poverty and racial differences in ESRD incidence.

Poverty is associated with increased risk of ESRD, but its contribution to observed racial differences in disease incidence is not well-defined. To explore the contribution of neighborhood poverty to racial disparity in ESRD incidence, we analyzed a combination of US Census and ESRD Network 6 data comprising 34,767 patients that initiated dialysis in Georgia, North Carolina, or South Carolina between January 1998 and December 2002. Census tracts were used as the geographic units of analysis, and the proportion of the census tract population living below the poverty level was our measure of neighborhood poverty. Incident ESRD rates were modeled using two-level Poisson regression, where race, age and gender were individual covariates (level 1), and census tract poverty was a neighborhood covariate (level 2). Neighborhood poverty was strongly associated with higher ESRD incidence for both blacks and whites. Increasing poverty was associated with a greater disparity in ESRD rates between blacks and whites, with the former at greater risk. This raises the possibility that blacks may suffer more from lower socioeconomic conditions than whites. The disparity persisted across all poverty levels. The reasons for increasingly higher ESRD incidence among US blacks as neighborhood poverty increases remain to be explained.

Relevance of Abusive Head Trauma to Intracranial Hemorrhages and Bleeding Disorders.

BACKGROUND: Bleeding disorders and abusive head trauma (AHT) are associated with intracranial hemorrhage (ICH), including subdural hemorrhage (SDH). Because both conditions often present in young children, the need to screen for bleeding disorders would be better informed by data that include trauma history and are specific to young children. The Universal Data Collection database contains information on ICH in subjects with bleeding disorders, including age and trauma history. Study objectives were to (1) characterize the prevalence and calculate the probabilities of any ICH, traumatic ICH, and nontraumatic ICH in children with congenital bleeding disorders; (2) characterize the prevalence of spontaneous SDH on the basis of bleeding disorder; and (3) identify cases of von Willebrand disease (vWD) that mimic AHT. METHODS: We reviewed subjects <4 years of age in the Universal Data Collection database. ICH was categorized on the basis of association with trauma. Prevalence and probability of types of ICH were calculated for each bleeding disorder. RESULTS: Of 3717 subjects, 255 (6.9%) had any ICH and 206 (5.5%) had nontraumatic ICH. The highest prevalence of ICH was in severe hemophilia A (9.1%) and B (10.7%). Of the 1233 subjects <2 years of age in which the specific location of any ICH was known, 13 (1.1%) had spontaneous SDH (12 with severe hemophilia; 1 with type 1 vWD). The findings in the subject with vWD were not congruent with AHT. CONCLUSIONS: In congenital bleeding disorders, nontraumatic ICH occurs most commonly in severe hemophilia. In this study, vWD is not supported as a "mimic" of AHT.

Predictors of improved HbA1c testing by primary care physicians.

Measurement of glycosylated hemoglobin (HbA1c) among patients with diabetes mellitus contributes to attaining control of blood glucose, which in turn is associated with fewer complications. Here, we seek to identify physician and county level characteristics that predict increased HbA1c testing among Medicare beneficiaries with diabetes who did not have testing in the baseline year. Physicians in counties with more people on Medicaid, or with fewer physicians per capita tended to have less improvement in HbA1c testing among Medicare beneficiaries over the three year study period.

Clinical characteristics of patients with early hospital arrival after stroke symptom onset.

BACKGROUND: Identifying characteristics of early arrivers after stroke may be useful to improve delivery of acute stroke treatment. We sought to identify the clinical characteristics and outcomes of patients with ischemic stroke who present early after symptom onset using data collected from a representative sample of hospitals in the state of Georgia. METHODS: Data were obtained retrospectively from a statewide observational stroke registry from December 1, 2001, to February 28, 2002, and from February 1 to March 31, 2003. Clinical characteristics of patients with stroke arriving to the hospital within 2 hours were compared with those arriving later. RESULTS: Of the 409 patients with ischemic stroke identified with a specified time of onset, 172 (42%) presented within 2 hours. Univariate analysis showed hospital arrival within 2 hours was associated with history of coronary artery disease (P = .0400), dyslipidemia (P = .0100), ambulance transport (P = .0285), stroke team consultation (P = .0070), higher National Institutes of Health Stroke Scale score (P < .0001), and lower Glasgow Coma Scale score (P = .0018). Race, sex, age, smoking history, previous stroke, myocardial infarction, congestive heart failure, prosthetic heart valve, hypertension, diabetes, and family history of stroke were not associated with arrival within 2 hours. Multivariate analysis revealed National Institutes of Health Stroke Scale score (odds ratio = 1.20, confidence interval 1.08-1.34, P = .0013) and Glasgow Coma Scale score (odds ratio = 0.84, confidence interval 0.75-0.94, P = .0027) were associated with arrival within 2 hours. Patients with stroke arriving within 2 hours had higher in-hospital mortality (13% v 4%) (P = .0284), but a higher rate of independent ambulation at discharge (55% v 37%) (P = .0419). CONCLUSIONS: Early arrival after ischemic stroke symptom onset is associated with increased stroke severity, higher mortality, and better functional outcome.

Improved diabetes care by primary care physicians: results of a group-randomized evaluation of the Medicare Health Care Quality Improvement Program (HCQIP).

BACKGROUND/OBJECTIVES: Glycosylated hemoglobin (HbA1C) measurements in patients with diabetes mellitus contribute to glycemic control, and, therefore to lower diabetic complication rates. Determine if an intervention that includes claims-based feedback about patterns of HbA1C measurement results in more frequent monitoring of HbA1C in diabetic Medicare beneficiaries. SUBJECTS: Primary care physicians in a single Southern state treating Medicare beneficiaries with diabetes mellitus. METHODS: A group-randomized evaluation of an intervention that included claims-based feedback about patterns of HbA1C measurement, educational materials, and practice aids. RESULTS: Rates for each quality indicator increased from 1996 to 1998 for both the intervention and comparison groups, although increases were larger for intervention counties. HbA1C testing rates increased in intervention counties 16.8% compared to 13.0% in the comparison counties, an absolute difference of 4.0% (95% CI, 0.7 to 7.3). Differences for other indicators were small, although positive and favoring the intervention, and lacked statistical significance. CONCLUSIONS: Physician interventions that included practice-level feedback about monitoring of glycemic control successfully led to improved care of diabetic Medicare beneficiaries.

Providing young women with credible health information about bleeding disorders.

BACKGROUND: Approximately 1% of U.S. women may have an undiagnosed bleeding disorder, which can diminish quality of life and lead to life-threatening complications during menstruation, childbirth, and surgery. PURPOSE: To understand young women's knowledge, attitudes, and perceptions about bleeding disorders and determine the preferred messaging strategy (e.g., gain- versus loss-framed messages) for presenting information. METHODS: In September 2010, a web-assisted personal interview of women aged 18-25 years was conducted. Preliminary analyses were conducted in 2011 with final analyses in 2013. In total, 1,243 women participated. Knowledge of blood disorders was tabulated for these respondents. Menstrual experiences of women at risk for a bleeding disorder were compared with those not at risk using chi-square analyses. Perceived influence of gain- versus loss-framed messages also was compared. RESULTS: Participants knew that a bleeding disorder is a condition in which bleeding takes a long time to stop (77%) or blood does not clot (66%). Of the women, 57% incorrectly thought that a bleeding disorder is characterized by thin blood; many were unsure if bleeding disorders involve blood types, not getting a period, or mother and fetus having a different blood type. Women at risk for a bleeding disorder were significantly more likely to report that menstruation interfered with daily activities (36% vs 9%); physical or sports activities (46% vs 21%); social activities (29% vs 7%); and school or work activities (20% vs 9%) than women not at risk. Gain-framed messages were significantly more likely to influence women's decisions to seek medical care than parallel loss-framed messages. Findings suggest that the most influential messages focus on knowing effective treatment is available (86% gain-framed vs 77% loss-framed); preventing pregnancy complications (79% gain- vs 71% loss-framed); and maintaining typical daily activities during menstrual periods. CONCLUSIONS: Lack of information about bleeding disorders is a serious public health concern. Health communications focused on gain-framed statements might encourage symptomatic young women to seek diagnosis and treatment. These findings and corresponding recommendations align with Healthy People 2020 and with CDC's goal of working to promote the health, safety, and quality of life of women at every life stage.

Insurance, home therapy, and prophylaxis in U.S. youth with severe hemophilia.

BACKGROUND: Home infusion therapy, particularly on a prophylactic regimen, is linked with reduced morbidity among youth with severe hemophilia. However, the association of insurance coverage with these home therapies is unknown. PURPOSE: This study explores the connections among insurance, home infusion therapy, and prophylaxis treatment in a nationwide cohort of 3380 boys and young men (aged 2 to 20 years) with severe hemophilia. These youth obtained care at one of 129 federally supported hemophilia treatment centers (HTCs), and enrolled in the CDC's bleeding disorder surveillance project. METHODS: Multiple regression was used to analyze the independent association among risk factors, including insurance, and both home infusion and prophylaxis. Data were obtained between January 1, 2008, and December 31, 2010, and analyzed in 2011. RESULTS: Ninety percent used home therapy and 78% a prophylaxis regimen. Only 2% were uninsured. Health insurance was significantly associated with prophylaxis, but not with home therapy. Lower prophylaxis utilization rates were independently associated with having Medicaid, "other," and no insurance as compared to having private insurance. Race, age, inhibitor status, and HTC utilization were also independently associated with both home therapy and prophylaxis. CONCLUSIONS: Youth with severe hemophilia who annually obtain care within the U.S. HTC network had a high level of health insurance, home therapy, and prophylaxis. Exploration of factors associated with insurance coverage and yearly HTC utilization, and interventions to optimize home infusion and prophylaxis among youth of African-American and "other" race/ethnic backgrounds are warranted.

Medicare patients with cardiovascular disease have a high prevalence of chronic kidney disease and a high rate of progression to end-stage renal disease.

The risk of progression to ESRD among individuals with cardiovascular disease and chronic kidney disease (CKD) is not well defined. The purpose of this study was to describe the risk of ESRD among patients with cardiovascular disease. Charts were abstracted for randomly selected hospitalized Medicare beneficiaries with a diagnosis of either congestive heart failure (CHF) or acute myocardial infarction (AMI). The prevalence of CKD, based on the estimated modified diet in renal disease GFR of <60 ml/min per m2, was 60.4% of CHF patients and 51.7% of AMI patients. When compared with patients without CKD, the 30-d readmission rate was higher for CHF patients with CKD (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.18 to 2.44) and for AMI patients with CKD (OR, 1.78; 95% CI, 1.17 to 2.70). CHF patients (OR, 1.62; 95% CI, 1.15 to 2.30) and AMI patients (OR, 3.10; 95% CI, 1.98 to 4.84) with CKD were more likely to die during the year after discharge from the hospital. ESRD after discharge occurred in nine of 517 patients with AMI and 24 of 640 patients with CHF. CKD increased the risk of ESRD among CHF patients (OR, 34.5; 95% CI, 4.23 to 279.43) and AMI patients (0 and 3% for those without and with CKD, respectively). At discharge, 18% of AMI patients and 21% of CHF patients with CKD were discharged with a diagnosis of renal disease. CKD is highly prevalent among patients with cardiovascular disease and is associated with increased risk of adverse outcomes, including progression to ESRD. This study suggests that opportunities may exist to improve the detection of CKD in these patients who are hospitalized with cardiovascular disease.

Renal insufficiency and anemia are independent risk factors for death among patients with acute myocardial infarction.

BACKGROUND: Chronic kidney disease (CKD) increases risk of death among patients with coronary artery disease. Mortality risks associated with CKD among patients with cardiovascular disease (CVD) are not well defined. Anemia is associated with increased mortality in end-stage renal disease (ESRD) patients and may also increase risk among patients with CVD. METHODS: A random sample of patients admitted to the hospital in a single southern state with a principal diagnosis of acute myocardial infarction (ICD-9 codes 410.xx) were followed up after hospital discharge. RESULTS: CKD was found in 60% of the cohort. Hematocrit of >or=40 was found in 46% of the patients; 26.0% had a hematocrit between 36% and 39%, 21.8% between 30% and 35%, and 5.9% had a hematocrit of less than 30%. The 1-year death rates among individuals with and without CKD were 31.7% and 10.4% respectively [odds ratio (OR) = 4.00 (2.34, 6.91)]. The mortality at one year was 18.6% for individuals with a hematocrit greater than or equal to 40%; 23.5% (OR = 1.35; 95% CI = 0.78, 2.32) for hematocrit 36% to 39%; 30.7% (OR = 1.94; 95% CI = 1.12, 3.34) for hematocrit between 30% and 35%; and 35.8% (OR = 3.16; 95% CI = 1.35, 7.40) for those with a hematocrit less than 30% (chi2 for trend was 12.2, P = 0.007). Both hematocrit and serum creatinine were independently associated with increased risk of death during follow-up after controlling for other patient risk factors. CONCLUSION: CKD and decreasing hematocrit were frequent among older patients hospitalized for acute myocardial infarction and are independent predictors of subsequent risk of death.

Anemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: a population-based study.

The purpose of this retrospective cohort study was to examine the associations among chronic kidney disease, anemia, and risk of death among patients with heart failure. Retrospective cohort study. Patients with a principal diagnosis of heart failure (ICD9 codes 402.01, 402.11, 402.91, 404.01, 404.11, 404.91, and 428.xx) were included. Chronic kidney disease (CKD) was defined as a serum creatinine >1.4 mg/dl for women and >1.5 mg/dl for men. There were 665 eligible patients in the sample with a mean (SD) age of 75.7 (10.9) yr; 60% were women, 71% were white, and 38% had CKD. On admission, a hematocrit > or =40% was found for 30.3% of the patients; 22.9% had a hematocrit between 36% and 40%, 33.2% between 30% and 35%, and 13.6% had a hematocrit of <30%. The 1-yr death rates among individuals with and without CKD were 44.9% and 31.4%, respectively (relative risk [RR], 1.43; 95% confidence interval [CI], 1.17 to 1.75). The mortality at 1 yr was 31.2% for individuals with a hematocrit > or =40%; 33.8% (RR, 1.08; 95% CI. 0.79 to 1.47) for hematocrit 36 to 39%; 36.7% (RR, 1.17; 95% CI, 0.89 to 1.54) for hematocrit between 30 and 35%; and 50.0% (RR, 1.60; 95% CI, 1.19 to 2.16) for those with a hematocrit <30% (chi(2) for trend was 7.37; P = 0.007). Both hematocrit and serum creatinine were independently associated with increased risk of death during follow-up after controlling for other patient risk factors. In conclusion, CKD and anemia are frequent among older patients with heart failure and are independent predictors of subsequent risk of death.

Administrative data as a tool for arthritis surveillance: estimating prevalence and utilization of services.

The public health burden of arthritis and related conditions is incompletely described by commonly used public health surveillance systems. We examined the potential of administrative data as a supplement. The administrative data sources we used underestimated the prevalence of arthritis and overestimated service utilization for persons with arthritis when data from only one year were used. The use of five year's data doubled the prevalence estimate and reduced the service utilization estimate by half. The demographics of the population covered by administrative data also influence the prevalence estimate. Administrative data may usefully supplement routine public health surveillance systems but must be used with caution.